The expectation is that patients who come to the hospital from their home, will be discharged to go home with appropriate community supports. This represents a significant shift in health provider philosophy, as hospital staff and physicians will now promote home as the primary discharge destination.
Working with our community partners, the patient and their family, a care plan will be developed upon admission to hospital that will support the safe discharge to home. The focus of the plan will be on what a patient and their family needs most to help them safely go home after their acute hospital stay has ended. They can recover and recuperate at home, and make any critical decisions about what is next, in a comfortable and familiar setting.
Generally, hospital patients will not be designated “ALC to Long-Term Care” until all other placement options have been exhausted and healthcare providers should avoid premature discussions with patients about specific placement upon discharge.
When given a choice, most seniors prefer to be at home than in a hospital. Outcomes are better when patients recuperate at home and with appropriate supports and they are not exposed to inherent risks of hospitals, including infection, pressure ulcers, risk of falls, lack of mobility and isolation.
Home First also promotes better use of healthcare resources. North Simcoe Muskoka has the worst Alternate Level of Care (ALC) situation in the province. Up to a third of our acute care beds are occupied by patients who do not need to be in hospital. If we are to be able to meet the acute care needs of our region, we must ensure patients receive the right care, in the right place at the right time. Home First must be a priority with everyone.
Home First is intended primarily for seniors, however the philosophy of recovering at home with community supports is being applied to all patients 18 years or older, regardless of their length of stay or condition.
The decision about whether to admit or discharge a patient remains the responsibility of the attending physician and/or nurse practitioner in consultation with the healthcare team. This team includes NSM CCAC Care Coordinators who arrange for care in the home or community.
Dedicated NSM CCAC Care Coordinators will work with hospital staff to identify high-needs patients and assess them soon after admission to hospital for discharge home, before long-term care or ALC or any other options are discussed.
Patients and their families will be partners in the process, communicated with and engaged from the very beginning.
The NSM CCAC now has more capacity to care for high-needs patients in the community, through intensive case management and enhanced service plans.
The NSM CCAC Care Coordinator will determine, in advance, what supports are required and will link the patient with community services when they are ready to go home. There are no additional care costs for many of these services and resources in the community are accessible via www.nsmhealthline.ca. Community support services, mental health and addiction services, and primary care will enable discharge to home and ensure that high needs patients are safely served in the community. Assistive living, supportive housing, adult day programs, complex continuing care and rehabilitation services are available pending eligibility by the NSM CCAC Care Coordinator.
Yes. Patients going home from hospital need the most help during the first two months. During this time, a NSM CCAC Care Coordinator will assess and support a patient’s needs and coordinate services to ensure they can recuperate comfortably in their own home. This provides a comfortable environment where a patient and their family can then make decisions about their future care.
There are no additional care costs to patients to transition home if they have been identified as high needs / complex and are eligible for the Hospital to Home enhanced service package through the NSM CCAC.